Acute appendicitis management during the COVID-19 pandemic: A prospective cohort study from a large UK centre. (February 2021) - Antakia, Ramez
Abstract: Background: During the Covid-19 pandemic, non‐operative management for acute appendicitis (AA) was implemented in the UK. The aim of this study was to determine the efficacy and outcomes of conservative versus surgical management of AA during the pandemic. Materials & Methods: We conducted an observational study in a tertiary referral centre. Data was collected from all patients (≥16 years) with a diagnosis of AA between November 1, 2019 to March 10, 2020 (pre-COVID period) and March 10, 2020 to July 5, 2020 (COVID period). Results: A total of 116 patients in the pre-COVID period were included versus 91 in the COVID period. 43.1% (n = 50) of patients pre-COVID were classified as ASA 2 compared to 26.4% (n = 24) during the COVID period (p-value = 0.042). 72.5% (n = 66) of the patients during the COVID period scored as high risk using the Alvarado score compared to 24.1% (n = 28) in the pre-COVID period (p-value<0.001). We observed a significant increase in radiological evaluation, 69.8% versus 87.5% of patients had a CT in the pre-COVID and COVID periods respectively (p-value = 0.008). 94.9% of patients were managed operatively in the pre-COVID period compared to 60.4% in the COVID period (p-value<0.001). We observed more open appendicectomies (37.3% versus 0.9%; p-value<0.001) during the COVID period compared to the pre-COVID period. More abscess formation and free fluid were found intraoperatively in the COVID period (p-value = 0.021 and 0.023 respectively). Re-attendance rate due to appendicitis-related issues was significantly higher in the COVID period (p = 0.027). Conclusion: Radiological diagnosis of AA was more frequent during the COVID period. More conservative management for AA was employed during the COVID-19 pandemic, and for those managed operatively an open approach was preferred. Intra-operative findings were suggestive of delayed presentation during the COVID period without this affecting the length of hospital stay. Highlights: This a prospective study looking at the management of acute appendicitis comparing COVID versus pre-COVID cohorts. Data collection and verification were carried out by 5 different independent investigators, hence very low risk of bias. 39 of 91 patients with were managed conservatively, out of which 6 failed conservative treatment and underwent surgery. 12 patients are awaiting interval appendicectomy, bringing the total failure rate to 46.15% (18/39). Three more patients are awaiting further investigations prior to definitive decision making. Patients managed conservatively needed follow up including investigations & imaging, that puts more load on health services. Operative findings during COVID were suggestive of delayed presentations, but this didn't affect length of hospital stay. Therefore we believe that prompt surgical treatment should still remain the main stay in managing acute appendicitis.